Clinical examination skills for first-level care
A good examination with a watch, a tape, a torch and a blood pressure cuff finds most of what a first-level worker needs to act on. Each lesson here is a checklist you can practise: the steps in order, what you are looking for, and what is abnormal and needs action. The steps follow WHO tools used in first-level care: the IMCI chart booklet, Basic Emergency Care, WHO PEN and HEARTS, the WHO antenatal recommendations, and the WHO primary ear and eye care training manuals.
- Measure and interpret vital signs in adults and children, including a full-minute breath count and the MUAC tape.
- Examine the chest, heart and abdomen and recognise the findings that need urgent action.
- Do a focused neurological check, a foot, skin and lymph node examination, and the IMCI examination of a sick child.
- Examine a pregnant woman: blood pressure, urine protein, fundal height, fetal heart and pallor.
- Test vision with an E chart and hearing with a whispered voice, look in the ear with an otoscope, and know when to refer.
Vital signs done properly, including breath counts and the MUAC tape
- Count breaths and pulse accurately and compare them with WHO normal ranges by age.
- Measure blood pressure the WHO HEARTS way.
- Measure MUAC correctly in a child aged 6 to 59 months and classify the result.
Source: WHO/ICRC/MSF Interagency Integrated Triage Tool (adult high-risk vital signs); IMCI chart booklet 2014
Before you start
Wash your hands, explain what you will do, and let the patient sit quietly. A crying child or an anxious adult breathes faster and has a faster pulse: wait, or count when they are calm or asleep.
Breathing rate
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Expose the chest or abdomen; the patient calm | Rise and fall of chest or belly | Breathing that is very fast, very slow or very shallow |
| 2. Count for one full minute with a watch | Breaths per minute; in a child, repeat if the count is borderline | Adult: normal 10 to 20; below 8 is a danger sign |
| 3. Compare with the child's age | IMCI cut-offs | Fast breathing: 60 or more under 2 months; 50 or more from 2 up to 12 months; 40 or more from 12 months up to 5 years |
| 4. Look at the work of breathing | Use of neck muscles, nasal flaring, chest indrawing (lower chest wall goes in when breathing in) | Chest indrawing, stridor in a calm child, grunting |
Source: IMCI chart booklet 2014; WHO-ICRC Basic Emergency Care 2018 (normal adult vital signs; B assessment)
Pulse and perfusion
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Feel the radial pulse (brachial in infants and small children) | Rate over a full minute, and whether it is regular | Adult outside 60 to 100; irregular rhythm (refer for assessment) |
| 2. Compare with age | Child normal heart rate: up to 1 year 100 to 160; 1 to 3 years 90 to 150; 4 to 5 years 80 to 140 | Fast pulse with cold hands, or a weak pulse |
| 3. Capillary refill: press on a fingernail, palm or sole, release, count seconds | Colour returns | More than 3 seconds, with cool hands and fast pulse: poor perfusion, think shock |
| 4. If you have no cuff | Which pulses you can feel | Only a carotid pulse suggests systolic pressure about 60 mmHg; femoral about 70; radial about 80 (a rough guide; may not work well in older people) |
Source: WHO-ICRC Basic Emergency Care 2018 (normal adult and paediatric vital signs; capillary refill)
Blood pressure
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Seat the person, back supported, legs uncrossed, bladder empty, resting 5 minutes and not talking | A relaxed patient | Talking or a full bladder raises the reading |
| 2. Choose the cuff by arm size | Large cuff if arm circumference is more than 32 cm | A cuff too small gives a falsely high reading |
| 3. Arm supported at heart level; use a validated automatic device if you have one | Systolic and diastolic in mmHg | Systolic below 90 in an adult with signs of poor perfusion: shock |
| 4. First time: take at least two readings a few minutes apart and use the second | A stable reading | 140/90 or more on two different days: hypertension (see the protocol) |
Source: WHO HEARTS technical package 2018 and WHO PEN 2020 (measuring blood pressure); WHO-ICRC Basic Emergency Care 2018
Temperature and oxygen
- Measure axillary temperature in children, holding the thermometer for the time its instructions give. In the young infant, fever (37.5 °C or above) or low temperature (below 35.5 °C) are signs of very severe disease.
- Pulse oximeter: warm finger, no nail polish, wait for a steady trace before reading. Child: refer if below 90%. Adult: below 92% is a high-risk sign.
Source: IMCI chart booklet 2014; WHO postnatal care recommendations 2022; Interagency Integrated Triage Tool
The MUAC tape (children 6 to 59 months)
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Bend the child's left arm to 90 degrees | The tip of the shoulder and the tip of the elbow | Do not use MUAC for this classification under 6 months |
| 2. Measure from shoulder tip to elbow tip; fold the tape to find the midpoint and mark it | The exact midpoint of the upper arm | A tape placed too high or low gives a wrong reading |
| 3. Straighten the arm; wrap the tape around the midpoint and thread it through the window | Tape snug against the skin: not loose, not squeezing | A tight tape gives a falsely low result; a loose one, falsely high |
| 4. Read where the arrows point, to the nearest millimetre, and record the colour | Green 125 mm or more | Red: below 115 mm = severe acute malnutrition. Yellow: 115 up to 125 mm = moderate acute malnutrition |
| 5. Always check both feet for pitting oedema too | Press thumbs on the top of both feet for 3 seconds | A dent that stays in both feet = nutritional oedema = severe acute malnutrition, whatever the MUAC |
Source: IMCI chart booklet 2014; WHO and UNICEF implementation guidance on the management of wasting and nutritional oedema 2026, Annexes 3 and 4
Infants 6 weeks to 6 months: a MUAC below 110 mm marks an infant at risk of poor growth and development. Pregnant and breastfeeding women: use the MUAC cut-off in your national guideline. See the protocol Acute malnutrition in a child.
Baby G is brought with cough and fever for 2 days. She is crying on her mother's lap. You count 62 breaths in 30 seconds while she cries and write 124 per minute. Her MUAC tape is wrapped over her sleeve and reads 118 mm. Her feet look normal.
What is wrong with the breath count?
It was counted for 30 seconds and doubled, in a crying child. IMCI requires a full minute in a calm child. Let her settle at the breast or wait until she is calm, then count again for one full minute. At 10 months, 50 or more is fast breathing (lesson 1).
What is wrong with the MUAC reading?
It was measured over clothing, which gives a falsely high reading, and without finding the midpoint. Remove the sleeve, bend the left arm to 90 degrees, find the midpoint, straighten the arm and read with the tape snug. Also press both feet for 3 seconds to check for oedema.
If the repeat MUAC is 113 mm, what does it mean?
Below 115 mm is severe acute malnutrition. With pneumonia (a medical complication) she needs urgent referral as complicated severe acute malnutrition, after pre-referral treatment per the IMCI chart.
- Count breaths for a full minute in a calm patient; IMCI fast breathing is 60, 50 or 40 or more depending on age.
- Capillary refill over 3 seconds with cool hands and a fast pulse means poor perfusion.
- Blood pressure: rested 5 minutes, back supported, right cuff (large if arm over 32 cm), two readings at the first visit.
- MUAC on the bare left arm at the midpoint, tape snug: below 115 mm is severe, 115 up to 125 mm is moderate; always check both feet for oedema.
Examining the chest and heart
- Examine the chest by looking, feeling, tapping and listening in a set order.
- Examine the heart and look for signs of heart failure.
- Recognise the chest findings that need emergency action.
Source: WHO-ICRC Basic Emergency Care 2018 (Breathing and Circulation conditions)
The chest
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Look: patient sitting, chest exposed with privacy | Rate, effort, both sides moving equally, shape of chest | Accessory muscle use, chest indrawing, nasal flaring; one side moving less |
| 2. Look at the neck | Position of the trachea; neck veins | Trachea shifted to one side; distended neck veins with low blood pressure |
| 3. Tap (percuss) both sides, top to bottom, comparing like with like | A similar, hollow note on both sides | Dull note on one side (fluid or blood in the chest); very hollow (hyperresonant) note with absent breath sounds (pneumothorax) |
| 4. Listen with the stethoscope, side to side, front and back, including the bases | Breath sounds equal on both sides | Wheeze (asthma, COPD); crackles (pneumonia, fluid); reduced or absent sounds on one side |
| 5. If available, measure oxygen saturation | A steady reading on a warm finger | Adult below 92%; child below 90% |
Source: WHO-ICRC Basic Emergency Care 2018 (B assessment and conditions table); IMCI chart booklet 2014
The heart and circulation
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Pulse rate and rhythm (lesson 1) | Regular rate within normal range | Irregular pulse; very fast or slow |
| 2. Feel the apex beat (where the heartbeat is felt most clearly on the left chest) | A tapping beat in the usual place below the left nipple | A heaving beat, or one displaced outwards or downwards (enlarged heart) |
| 3. Listen over the heart: rhythm and any murmur | Two clear heart sounds, regular | A murmur (in a child or young adult, think rheumatic heart disease); muffled sounds with low blood pressure |
| 4. Listen to the lung bases | Clear | Crackles at both bases: fluid on the lungs (heart failure) |
| 5. Press over the shins and ankles for a few seconds | No dent | Pitting oedema of both legs; with crackles and breathlessness, think heart failure |
| 6. Feel the liver below the right ribs | Not tender | Tender, enlarged liver in heart failure |
Source: WHO PEN 2020, CVD risk assessment and management (physical examination); WHO-ICRC Basic Emergency Care 2018; WHO guideline on rheumatic fever and RHD 2024
Reasoning from the findings
- Fever, cough, fast breathing, crackles on one side
- Pneumonia
- Wheeze, cough, accessory muscles, history of asthma or smoking
- Asthma or COPD: give salbutamol
- Breathless, crackles at both bases, oedema of both legs, raised neck veins
- Heart failure and fluid overload
- Breathless with pain and swelling of one leg, or after recent pregnancy
- Possible clot on the lung (pulmonary embolism): refer urgently
- Chest pain with breathlessness
- Heart attack, pneumothorax, pneumonia or chest injury: follow the ABCDE approach
Source: WHO-ICRC Basic Emergency Care 2018, Difficulty in breathing module
See the protocols Asthma in adults, COPD and Rheumatic heart disease.
Mr H has hypertension. He says he gets breathless walking to the market and has had to sleep on three pillows for a month. Pulse 108 and irregular, BP 150/95, breathing 26 per minute, saturation 93%. Both ankles pit when pressed. You hear crackles at both lung bases. The apex beat is felt in the armpit line.
What do the findings suggest?
Heart failure with fluid overload: breathless on exertion and lying flat, crackles at both bases, oedema of both legs, displaced apex beat. The irregular pulse suggests an arrhythmia such as atrial fibrillation (lesson 2).
Which findings make you worried today?
Breathing 26 per minute, saturation 93% and a fast irregular pulse. He is not yet in the adult high-risk band (saturation below 92%, breathing above 30), but he needs same-day assessment by a clinician who can start diuretic treatment, and referral for heart assessment and the irregular rhythm.
What should you record?
Full vital signs, apex position, crackles, oedema level, liver, weight. These give a baseline to judge treatment.
- Chest: look, check the trachea and neck veins, tap side to side, listen side to side including the bases.
- Dull note with reduced sounds suggests fluid; hyperresonance with absent sounds and low BP suggests tension pneumothorax.
- Heart: rate and rhythm, apex beat, heart sounds and murmurs, basal crackles, pitting oedema, tender liver.
- A murmur in a child or young adult may be rheumatic heart disease: refer for echocardiography where available.
Examining the abdomen
- Examine the abdomen in a set order and describe what you find.
- Recognise the signs of an acute abdomen and of internal bleeding.
- Know the abdominal warning signs of cancer and dehydration in a child.
Source: WHO-ICRC Basic Emergency Care 2018 (Shock module; Trauma secondary survey)
Before you touch
Explain, get consent, offer a chaperone, and keep the patient covered except for the abdomen. Ask the patient to lie flat with arms by the sides and knees slightly bent. Ask where it hurts, and examine that area last. Watch the face, not your hands.
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Look | Shape, movement with breathing, scars, swelling | Distension; bruising on the abdomen or back (internal bleeding); visible lumps; wounds |
| 2. Feel lightly, all areas, painful area last | Soft, not tender | Tenderness; guarding (the muscles tighten when you press) |
| 3. Feel more deeply | Any mass | A mass; tender enlarged liver under the right ribs; enlarged spleen under the left ribs |
| 4. Check for rebound | No pain when pressure is released | Pain when you release the pressure: inflamed peritoneum |
| 5. Tap (percuss) | Hollow note over bowel | Dull note in the flanks that moves when the patient turns (fluid) |
| 6. Listen | Bowel sounds present | Silent abdomen, or high-pitched sounds with distension and vomiting (blockage) |
| 7. Check hernial openings in the groins | No lump | A tender, hard lump that does not go back: strangulated hernia, refer urgently |
| 8. Ask about urine; look at it if possible | Normal amount and colour | Small amounts of dark urine: significant dehydration |
Source: WHO-ICRC Basic Emergency Care 2018 (secondary survey of the abdomen; Shock module); WHO PEN 2020 (tender liver)
Abdominal warning signs of cancer (WHO PEN)
| Possible cancer | Symptoms to act on |
|---|---|
| Stomach | Upper abdominal pain, recent onset of indigestion, weight loss |
| Bowel (colon, rectum) | Change in bowel habit, unexplained weight loss, anaemia, blood in the stool |
| Bladder | Pain, frequent and difficult urination, blood in the urine |
| Cervix | Bleeding after sex, excessive vaginal discharge |
Source: WHO PEN 2020, early diagnosis of common cancers
The child's abdomen and hydration
- Skin pinch: pinch the skin of the abdomen halfway between the navel and the side, hold for a second and release. Very slow return (more than 2 seconds) or slow return are IMCI signs of dehydration.
- Look for sunken eyes and offer a drink: not able to drink or drinking poorly, or drinking eagerly, help classify severe or some dehydration.
- Any general danger sign with abdominal pain or vomiting everything needs urgent referral.
Source: IMCI chart booklet 2014 (diarrhoea assessment)
Ms I comes with lower abdominal pain since this morning. She felt faint at home. Her last period was 7 weeks ago. Pulse 118, BP 88/60, capillary refill 4 seconds. The lower abdomen is tender with guarding. There is a little vaginal bleeding.
What is the most likely diagnosis?
Ruptured ectopic pregnancy with internal bleeding and shock: missed period, abdominal pain, vaginal bleeding, fast pulse, low BP, slow capillary refill, guarding (lesson 3).
What do you do?
ABCDE approach: lay her flat, oxygen if available, IV access and IV fluids, and urgent transfer to a facility with surgery and blood transfusion. Do not delay transfer to do a pregnancy test.
- Look, feel lightly, feel deeply, check rebound, percuss, listen; examine the painful area last and watch the face.
- Guarding, rebound or a rigid abdomen, especially with shock, needs urgent surgical referral.
- Any woman of childbearing age with abdominal pain and bleeding or a missed period: think ectopic pregnancy.
- In a child, skin pinch, sunken eyes and ability to drink classify dehydration.
The nervous system in 10 minutes
- Do a quick, structured neurological check: consciousness, pupils, speech, face, limbs, reflexes, sensation and gait.
- Recognise the signs of stroke, raised pressure in the head, meningitis and nerve damage.
- Always check the blood glucose in a confused or unconscious person.
Source: WHO-ICRC Basic Emergency Care 2018 (Disability assessment; Altered mental status); IMCI chart booklet 2014
The 10-minute check
| Step (about 1 minute each) | What you are looking for | What is abnormal |
|---|---|---|
| 1. Level of consciousness: AVPU | Alert | Responds only to Voice, only to Pain, or Unresponsive |
| 2. Blood glucose in anyone confused or drowsy | Normal glucose | Below 3.5 mmol/L, or cannot be measured with altered mental status: give glucose now |
| 3. Pupils: size, equal, reaction to torch light | Equal pupils that get smaller in light | Unequal pupils (raised pressure in the head); pinpoint pupils with slow breathing (opioids) |
| 4. Speech and understanding | Clear speech, follows a command | Slurred speech, wrong words, cannot understand |
| 5. Face: ask to smile, shut eyes tight, puff cheeks | Both sides move equally | One side droops: stroke, or facial nerve palsy (for example from an ear infection) |
| 6. Arms and legs: hold arms out, push and pull, lift each leg | Equal strength both sides | Weakness of one side (stroke); weakness of both legs (spinal cord problem) |
| 7. Sensation: light touch on hands and feet, comparing sides | Felt equally | Loss in both feet (neuropathy); loss on one side; a numb skin patch (leprosy) |
| 8. Reflexes: knee jerk with a tendon hammer or the edge of the hand | A brisk, equal response | Absent; very brisk with repeated beats (clonus): in pregnancy, a sign of severe pre-eclampsia |
| 9. Neck: gently bend the head forward (not after injury) | Chin reaches the chest without pain | Stiff neck with fever: meningitis |
| 10. Walking, if safe | Steady gait | Unsteady, dragging one leg, cannot walk |
Source: WHO-ICRC Basic Emergency Care 2018 (D assessment, AMS module); IMCI chart booklet 2014 (stiff neck); WHO primary ear and hearing care training manual 2023 (facial palsy); MCPC 2017 (hyperreflexia and patellar reflexes); WHO leprosy fact sheet
Putting it together
- Sudden weakness of one side, facial droop, speech trouble
- Stroke (always check glucose first: low sugar can look the same)
- Headache, vomiting, drowsiness, unequal pupils
- Raised pressure in the head: raise the head of the bed 30 degrees if no spinal injury, transfer
- Fever, stiff neck, drowsiness or convulsions
- Meningitis or severe malaria: first doses per protocol, refer urgently
- Burning feet, loss of feeling in a stocking pattern
- Peripheral neuropathy: diabetes, HIV, medicines; protect the feet (lesson 5)
- Pale or reddish skin patch with definite loss of feeling, or a thickened nerve
- Leprosy (lesson 5)
Source: WHO-ICRC Basic Emergency Care 2018; WHO leprosy fact sheet (cardinal signs)
Mrs J's son brings her because this morning she could not lift her cup with her right hand and her speech is slurred. She is alert. BP 178/104, pulse 88 irregular. Her pupils are equal. The right side of her mouth droops when she smiles and her right arm drifts down when held out.
What must you check before calling this a stroke?
Blood glucose. Low glucose can cause the same signs and is quickly reversible (lesson 4).
Glucose is 7 mmol/L. What next?
Likely stroke (sudden one-sided weakness, facial droop, speech problem). Record the time she was last well, protect the airway, and refer urgently to a hospital that can manage stroke. The irregular pulse is a possible cause.
- AVPU, glucose, pupils, speech, face, limbs, sensation, reflexes, neck, gait.
- Always check glucose in a confused or drowsy person; give glucose if below 3.5 mmol/L or unmeasurable.
- One-sided weakness or facial droop: stroke until proved otherwise; unequal pupils: raised pressure in the head.
- Fever with stiff neck: meningitis; very brisk reflexes in pregnancy: severe pre-eclampsia.
Feet, skin and lymph nodes
- Examine the diabetic foot: inspection, pulses and protective sensation.
- Examine the skin for leprosy, cancer warning signs and pressure damage.
- Examine lymph nodes and know which findings need investigation.
Source: WHO HEARTS-D 2020 (foot); WHO PEN 2020 (cancer warning signs); WHO consolidated TB guidelines, screening (W4SS)
The diabetic foot (every visit; full risk check yearly)
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Remove shoes and socks; look at both feet, between toes and the soles | Healthy skin, nails, normal shape | Ulcer, callus, blister, fungal infection, deformity, colour change |
| 2. Look at the shoes | Shoes that fit and protect | Tight or worn shoes, objects inside |
| 3. Feel the dorsalis pedis (top of foot) and posterior tibial (behind the inner ankle) pulses | Both pulses present on each foot | Absent pulses: refer for circulation assessment |
| 4. Monofilament (10 g): show it on the hand first; patient's eyes closed; press at 3 sites on each foot until it bends, about 2 seconds; include a mock touch | Each touch is felt | Not felt: loss of protective sensation. Never test on an ulcer, callus or dead skin |
| 5. No monofilament: light touch with the index finger on the tips of the 1st, 3rd and 5th toes for 1 to 2 seconds | All felt | Two or more sites not felt: loss of protective sensation likely |
Source: WHO HEARTS-D 2020 (foot examination, monofilament and Ipswich touch test); WHO PEN 2020
Risk and follow-up: see the protocol Diabetic foot: examine, classify, protect.
Skin
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. In good daylight, look at all the skin the patient agrees to show | Even skin | Patches, sores, lumps, rashes |
| 2. For any pale or reddish patch: test light touch with a wisp of cotton, eyes closed, comparing with normal skin | Felt equally | Definite loss of feeling in the patch: leprosy (a cardinal sign) |
| 3. Feel the nerves at the elbow and behind the knee | Not thickened | Thickened or tender nerve with numbness or weakness: leprosy |
| 4. Look at moles and sores | Stable, regular moles | A growing brown patch with irregular edges or patchy colour that itches or bleeds; a sore that does not heal: possible skin cancer |
| 5. In bed-bound patients: heels, hips, base of the spine, shoulders | Intact skin | Redness that does not fade, broken skin: pressure damage |
Source: WHO leprosy fact sheet (cardinal signs, PB and MB); WHO PEN 2020 (skin cancer signs); Integrating palliative care into primary health care, WHO 2018 (pressure-reducing mattresses)
Leprosy treatment groups: 1 to 5 skin patches with no bacilli on a smear is paucibacillary; more than 5 patches, nerve involvement or bacilli on a smear is multibacillary. WHO multidrug therapy lasts 6 months (paucibacillary) or 12 months (multibacillary). Refer suspected cases to your leprosy programme.
Lymph nodes
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Neck: stand behind the seated patient; feel under the jaw, along the front and back of the neck, above the collarbones | Small, soft, mobile, non-tender nodes are common | Nodes in the upper neck with nosebleeds, a blocked nose or deafness (nasopharyngeal cancer warning) |
| 2. Armpits: support the patient's arm and feel high in the armpit | No large nodes | Hard nodes, especially with a breast lump |
| 3. Groins | Small soft nodes are common | Large, tender or discharging nodes (consider STI or TB) |
| 4. For each node record site, size in cm, tender or not, soft or hard, mobile or fixed, single or matted | A clear record to compare later | Hard, fixed, matted, growing or discharging nodes |
| 5. Ask the four TB questions: cough now, fever, weight loss, night sweats | None | Any of these, especially in a person with HIV: test for TB |
Source: WHO PEN 2020 (cancer warning signs: nasopharynx, breast); WHO consolidated guidelines on tuberculosis, Module 2: screening 2021 (W4SS)
Mr K has had type 2 diabetes for 9 years. At his review you ask him to take off his shoes. There is a thick callus under the right big toe joint with a small dark spot in it. Both foot pulses are present. He does not feel the light touch test on the tips of toes 1 and 5 of either foot. He also has a pale patch on his forearm.
What do the foot findings mean?
Loss of protective sensation (two or more sites not felt on the light touch test) and a callus with a dark spot, which may be bleeding under the callus, a sign of a pre-ulcer. He is at raised risk of ulceration (lesson 5).
What will you do about the foot?
Callus care by a trained professional, protective footwear, daily foot checks by him or his family, and more frequent review as per the diabetic foot protocol. Refer if there is no trained professional, or at once if an ulcer becomes infected.
How do you examine the pale patch?
Test light touch in the patch with his eyes closed, comparing with normal skin, and feel the nerves at the elbow. Remember that diabetic neuropathy affects the feet in a stocking pattern; a numb patch on the forearm points to leprosy and needs referral to the leprosy programme.
- Diabetic foot: look, check shoes, feel two pulses each side, and test protective sensation (monofilament or toe touch test).
- A pale or reddish patch with definite loss of feeling, or a thickened nerve, is a cardinal sign of leprosy.
- A growing irregular brown patch or a sore that does not heal needs referral.
- Record node site, size, consistency and mobility; ask the four TB questions.
Examining the sick child the IMCI way
- Follow the IMCI order: danger signs, main symptoms, malnutrition, anaemia, immunisation, other problems.
- Perform the IMCI look-and-feel signs correctly on a child aged 2 months to 5 years.
- Check a young infant up to 2 months for signs of very severe disease.
Source: IMCI chart booklet 2014
The IMCI order (child aged 2 months up to 5 years)
| Step | How to do it | What is abnormal |
|---|---|---|
| 1. Danger signs | Ask: able to drink or breastfeed? Vomits everything? Convulsions? Look: lethargic or unconscious? Convulsing now? | Any danger sign |
| 2. Cough or difficult breathing | Count breaths for one minute in a calm child; lift the shirt and look at the lower chest wall; listen for stridor and wheeze; saturation if available | Fast breathing for age; chest indrawing; stridor in a calm child; saturation below 90% |
| 3. Diarrhoea | Look at general condition; look for sunken eyes; offer a drink; pinch the abdominal skin | Lethargic or restless; sunken eyes; drinks poorly or eagerly; skin goes back slowly or very slowly; blood in stool |
| 4. Fever | Decide malaria risk; feel for stiff neck; look for runny nose, measles rash, mouth ulcers, cloudy cornea | Stiff neck (very severe febrile disease); measles with complications |
| 5. Ear problem | Ask about pain and discharge and for how long; look for pus; feel for tender swelling behind the ear | Tender swelling behind the ear (mastoiditis); pus less than 14 days (acute) or 14 days or more (chronic) |
| 6. Acute malnutrition | Look for oedema of both feet; measure MUAC (6 months or older) or weight-for-length/height | Oedema of both feet or MUAC below 115 mm: severe; 115 up to 125 mm: moderate |
| 7. Anaemia | Compare the child's palm with your own and with a healthy child's | Severe palmar pallor (refer); some palmar pallor (iron, follow up) |
| 8. Immunisation, vitamin A, deworming, feeding, other problems | Check the card; ask about feeding | Missed doses; feeding problems |
Source: IMCI chart booklet 2014 (Assess and classify the sick child)
Doing the signs well
- Chest indrawing: look at the lower chest wall (lower ribs) as the child breathes in. It is indrawing only if it goes in on every breath in, with the child calm, not only when crying or feeding.
- Skin pinch: pinch the skin of the abdomen halfway between the navel and the side, with the fold running up and down the body, using thumb and first finger, not fingertips. Hold one second, release, watch.
- Oedema of both feet: press thumbs on the top of both feet for 3 seconds. A dent that stays in both feet is nutritional oedema. Oedema of nutritional origin is always on both sides and starts in the feet.
- Palmar pallor: hold the child's palm open gently; if you stretch the fingers back, the palm looks paler than it is.
Source: IMCI chart booklet 2014; WHO and UNICEF implementation guidance on wasting and nutritional oedema 2026, Annex 3
The young infant up to 2 months
| Step | What you are looking for | What is abnormal |
|---|---|---|
| Watch a breastfeed; ask about feeding and convulsions | Good attachment and suckling | Not feeding well; convulsions |
| Count breaths for one minute; repeat if 60 or more | Under 60 | 60 or more; severe chest indrawing |
| Measure axillary temperature | Normal | Fever (37.5 °C or more) or low temperature (below 35.5 °C) |
| Look at movements; wake the infant if asleep | Moves on its own | Moves only when stimulated, or not at all |
| Look at the umbilicus and skin | Clean, dry | Red or draining pus; skin pustules (local infection) |
| Look for jaundice (eyes, palms, soles) | None | Any jaundice in the first 24 hours, or yellow palms and soles at any age: severe |
Source: IMCI chart booklet 2014 (young infant); WHO postnatal care recommendations 2022
For the full classification and treatment, see the course The sick child: IMCI in practice and the protocol The sick young infant.
Child L has had diarrhoea for 4 days. She is restless and irritable, and her eyes look sunken. When offered water she drinks eagerly. The skin pinch goes back slowly. She has no danger signs. Her palms look a little pale. Her MUAC is 121 mm and there is no oedema.
How do you classify her diarrhoea?
Some dehydration: two or more of restless or irritable, sunken eyes, drinks eagerly, skin pinch goes back slowly (lesson 6). Give ORS by Plan B in the clinic and zinc, per the IMCI chart.
What other classifications does she have?
Moderate acute malnutrition (MUAC 115 up to 125 mm, no oedema) and anaemia (some palmar pallor). Both need treatment, feeding counselling and follow-up per the chart.
What is the most common mistake with the skin pinch?
Pinching with fingertips or across the body, or in a wasted child where the skin is loose anyway. Use thumb and first finger, fold up and down the body, halfway between navel and side.
- Danger signs first in every sick child; any one means urgent referral after pre-referral treatment.
- Chest indrawing counts only if present on every breath in a calm child.
- Skin pinch on the abdomen with thumb and first finger; oedema with 3 seconds of thumb pressure on both feet.
- In a young infant, 60 or more breaths, severe indrawing, fever or low temperature, or poor movement are signs of very severe disease.
The pregnancy examination: blood pressure, oedema, fundal height
- Measure blood pressure and urine protein in pregnancy and recognise pre-eclampsia.
- Measure symphysis-fundal height and interpret it.
- Listen for the fetal heart and check for pallor and danger signs.
Source: WHO PCPNC 2015 (danger signs); WHO MCPC 2017 (classification of hypertensive disorders)
Blood pressure and urine
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. BP sitting, rested, right cuff (lesson 1) | Below 140/90 | Diastolic 90 or more |
| 2. If diastolic is 90 or more, repeat after 1 hour of rest | Falls below 90 | Still 90 or more |
| 3. If still raised, ask about severe headache, blurred vision, epigastric pain; test urine for protein | No symptoms, no protein | Protein 2+ or more on a clean-catch sample, or any symptom: pre-eclampsia |
| 4. Check knee reflexes if pre-eclampsia is suspected | Normal | Very brisk reflexes or clonus: severe pre-eclampsia |
Source: WHO PCPNC 2015 (check for pre-eclampsia); WHO MCPC 2017 (Table S-12, proteinuria)
Source: WHO MCPC 2017; WHO PCPNC 2015
Symphysis-fundal height
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Woman lying on her back, knees slightly bent, bladder empty; explain and keep her covered | A relaxed abdomen | |
| 2. Feel for the top of the uterus (fundus) with the side of your hand, walking down from below the ribs | The firm upper edge | |
| 3. Place the zero of the tape on the top edge of the pubic bone; run the tape over the bump to the fundus; read in cm | From 24 weeks, the height in cm roughly equals the weeks of pregnancy, within 2 cm either way | More than 2 cm below or above the expected value |
| 4. Record and compare with the last visit | Steady growth | No growth between visits |
Source: WHO recommendations on antenatal care for a positive pregnancy experience 2016 (B.2.2 and its background)
WHO 2016 does not recommend replacing abdominal palpation with tape measurement, or the reverse: keep the method your service uses, and use it well. A small-for-dates fundus may mean growth restriction or wrong dates; a large one, twins, too much fluid or a large baby. Refer for ultrasound or a senior opinion.
Fetal heart, movements and lie
- Ask about fetal movements and feel for them.
- After 6 months of pregnancy, listen for the fetal heart with a fetal stethoscope or Doppler, over the baby's back. If you cannot hear it, repeat after 1 hour; if still absent, refer.
- Near term, feel the lie: a transverse lie or other malpresentation within one month of the due date, or an obvious twin pregnancy, means planning birth at a referral-level facility.
Source: WHO PCPNC 2015 (assess the pregnant woman; place of delivery)
Pallor
Look at the inside of the lower eyelid and the palms. Severe palmar and conjunctival pallor, or any pallor with more than 30 breaths per minute, tiring easily or breathlessness at rest, means severe anaemia: refer urgently. Confirm with haemoglobin where possible.
Source: WHO PCPNC 2015 (anaemia in pregnancy)
See the protocols Routine antenatal contacts and Hypertension in pregnancy and pre-eclampsia.
Mrs M, in her first pregnancy, is 30 weeks by her dates. Her BP is 146/94; after an hour's rest it is 144/92. She has no headache or visual problems. Urine dipstick shows protein 2+. Her ankles are swollen. The fundal height is 26 cm.
What is your diagnosis?
Pre-eclampsia: diastolic 90 or more on repeat after 20 weeks, with proteinuria 2+, no severe features yet (lesson 7). The ankle swelling does not add to the diagnosis.
What does the fundal height suggest?
At 30 weeks the expected SFH is about 30 cm (28 to 32 cm). At 26 cm she is more than 2 cm small for dates: possible fetal growth restriction, which is linked to pre-eclampsia, or wrong dates.
What do you do?
Refer to a hospital for assessment of mother and baby, as your national protocol requires for pre-eclampsia. Teach her the danger signs: severe headache, blurred vision, epigastric pain, convulsions, reduced fetal movements.
- Diastolic 90 or more: repeat after 1 hour rest; if still raised, ask about symptoms and test for protein.
- Oedema alone is not a reliable sign of pre-eclampsia; check BP and urine.
- From 24 weeks, SFH in cm roughly equals weeks, within 2 cm either way.
- After 6 months listen for the fetal heart; if absent, repeat after 1 hour, then refer.
Eyes and ears with simple tools
- Test distance vision with an E chart at 3 metres and near vision at 40 cm.
- Use the WHO red eye algorithm to decide when to refer.
- Examine the ear with an otoscope, test hearing with a whispered voice, and know when to refer.
Source: WHO AFRO Primary eye care training manual 2018 (algorithms 1 to 5); WHO Primary ear and hearing care training manual 2023; WHO PEN 2020 (retinoblastoma)
Distance vision (E chart at 3 metres)
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Good light, not facing the sun; spectacles on if worn for distance | ||
| 2. Show the person the E and ask them to point which way the arms face | They understand the task | |
| 3. Measure 3 metres with a string; cover the left eye | ||
| 4. Point to the 6/60 Es | Points correctly | Cannot see 6/60: functionally blind in that eye; refer urgently |
| 5. Point to each 6/12 E | 4 or 5 of the 5 correct: normal (record R 6/12) | 1 to 3 correct: cannot see 6/12; abnormal distance vision; refer |
| 6. Repeat for the left eye |
Source: WHO AFRO Primary eye care training manual 2018 (distance vision screening procedure)
Near vision (age 40 and over)
With distance vision normal, ask the person to hold the N8 near chart at 40 cm. If they cannot read it, try reading glasses from +1.50 upwards (+1.50, +2.00, +2.50, +3.00) until it is clear, then try one step weaker and let them choose. If they cannot read N8 with any of these, refer.
Source: WHO AFRO Primary eye care training manual 2018
Look at the eyes
- The white should be white (a few red vessels are normal).
- The black (pupil) should be completely black; in a child, a white pupil may be retinoblastoma.
- The eyes should be the same size and look straight ahead.
- With the eyes closed, lids should close fully; lashes should point outwards, not rub the eye.
The red eye: decide by vision and pain
| Finding | Action |
|---|---|
| Vision reduced, sudden | Refer urgently; help pain, discharge or itch meanwhile |
| Vision reduced, gradual | Refer |
| Vision normal, moderate to severe pain | Give a painkiller and refer urgently |
| Vision normal, mild pain | Painkiller, with or without lubricating drops; refer urgently if worse or no better in 2 days |
| Vision normal, discharge (pus) | Show how to wash the eyes; topical antibiotic; refer urgently if worse or no better in 2 days |
| Vision normal, itchy and watering | Wash with cold water often; allergy medicine |
| Redness only: no pain, discharge or itch | Reassure |
Source: WHO AFRO Primary eye care training manual 2018, Algorithm 2 (red eye); Algorithm 4 (trauma: irrigate chemical injuries for 10 minutes, then refer urgently)
Ear examination with an otoscope
| Step | What you are looking for | What is abnormal |
|---|---|---|
| 1. Wash hands; ask about pain; seat the patient at your height. A young child sits sideways on the carer's lap, head held against the carer's chest | ||
| 2. Look at and behind the pinna; press the tragus | No swelling or pain | Swelling, redness, pain behind the ear (mastoiditis); pain on pressing the tragus (outer ear infection) |
| 3. Largest speculum that fits; hold the otoscope like a pen, steadied on the cheek | ||
| 4. Straighten the canal: pull the pinna up and back (adult) or straight back (young child); insert gently, pointing towards the eye, no more than half the speculum | Clear canal | Pus, swelling, wax, foreign body; if pus blocks the view, dry mop and look again |
| 5. Look at the ear drum | Pearly grey, intact | Red and bulging; a hole (perforation); pulled in; white debris (cholesteatoma: refer) |
Source: WHO Primary ear and hearing care training manual 2023 (Practical B: otoscopy)
The whispered voice test (over 7 years and adults)
- Quiet room. Stand behind the seated person, at arm's length, so they cannot read your lips.
- Ask them to block the other ear with a finger on the tragus, moving it in small circles.
- Breathe out fully, then whisper a number-letter-number set, such as 4-K-2, and ask them to repeat it.
- If wrong, try a different set. Passing is repeating at least 3 of the 6 items over two attempts.
- Test the other ear with different sets. Record the result. If in doubt, refer for a hearing test.
Source: WHO Primary ear and hearing care training manual 2023 (Practical H); younger children: voice test (3 to 7 years) and distraction test for babies
IMCI ear classification (children 2 months to 5 years)
| Signs | Classify | Action |
|---|---|---|
| Tender swelling behind the ear | Mastoiditis | First dose of an appropriate antibiotic and paracetamol; refer urgently |
| Pus seen, discharge for less than 14 days, or ear pain | Acute ear infection | Antibiotic for 5 days, paracetamol, dry the ear by wicking, follow up in 5 days |
| Pus seen, discharge for 14 days or more | Chronic ear infection | Dry the ear by wicking; topical quinolone ear drops for 14 days; follow up in 5 days |
| No pain, no pus | No ear infection | No treatment |
Source: IMCI chart booklet 2014
Mr N, a driver, says his right eye has been red and painful since yesterday and that "things look misty". On the E chart at 3 metres his right eye sees 6/60 but only 2 of the 6/12 Es; his left eye sees 4 of 5. His son, 8, has had a smelly discharge from the left ear for 3 weeks and now does well only on the whispered voice test in the right ear.
How do you manage Mr N's eye?
A red eye with sudden reduced vision (cannot see 6/12 in the right eye) and pain: refer urgently, giving a painkiller meanwhile. Do not treat as simple conjunctivitis. Advise him not to drive until assessed (lesson 8).
What does his son likely have, and what do you look for?
Chronic suppurative otitis media (discharge more than 2 weeks), with hearing loss in the left ear. Look with the otoscope after dry mopping for a perforation or cholesteatoma, and check behind the ear for swelling. Ask about headache, vomiting, dizziness, drowsiness, fits or facial weakness, which would need urgent referral.
What treatment and follow-up?
Dry the ear by wicking and topical quinolone drops for 14 days (as IMCI gives for chronic ear infection), review, and refer to a doctor or ENT service for the hearing loss and if discharge persists or a cholesteatoma is seen.
- E chart at 3 m: cannot see 6/12 is abnormal (refer); cannot see 6/60 is functional blindness (refer urgently).
- Red eye: sudden reduced vision or moderate to severe pain means urgent referral.
- Otoscopy: pull the pinna up and back in adults, straight back in young children; look at canal and drum.
- Whispered voice test at arm's length behind the person; ear discharge for 14 days or more is chronic; tender swelling behind the ear is mastoiditis.
Quiz and CPD certificate
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Sources
- World Health Organization and UNICEF. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014 (ISBN 9789241506823).
- World Health Organization and International Committee of the Red Cross. Basic emergency care: approach to the acutely ill and injured. 2018 (ISBN 9789241513081).
- World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020.
- World Health Organization. HEARTS technical package for cardiovascular disease management in primary health care: evidence-based treatment protocols. 2018.
- World Health Organization. Diagnosis and management of type 2 diabetes (HEARTS-D). 2020 (WHO/UCN/NCD/20.1).
- World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 2016 (ISBN 9789241549912).
- World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd edition. 2015.
- World Health Organization. Managing complications in pregnancy and childbirth: a guide for midwives and doctors, 2nd edition. 2017 (ISBN 9789241565493).
- World Health Organization. Primary ear and hearing care: training manual. 2023 (ISBN 9789240069152).
- World Health Organization Regional Office for Africa. Primary eye care training manual. 2018 (ISBN 9789290234067).
- World Health Organization and UNICEF. Implementation guidance on the management of wasting and nutritional oedema (acute malnutrition) in infants and children aged under 5 years in inpatient and outpatient settings. 2026 (ISBN 9789240122840).
- World Health Organization. Leprosy: fact sheet. 2026.
- World Health Organization. WHO consolidated guidelines on tuberculosis. Module 2: screening. 2021.
- World Health Organization, ICRC and MSF. Interagency Integrated Triage Tool. 2023.